trauma Flashcards
(189 cards)
1
Q
what are the zones of the neck
A
zone 1: clavicle to cricoid cartilage
zone 2: cricoid cartilage to angle mandible
zone 3: angle of mandible to base of skull
2
Q
what are the “hard signs” of clinical exam of neck penetration that necessitate immediate surgery
A
- expanding hematoma
- active/pulsatile bleeding
- bruit
- thrill
- airway compromise/obstruction
- refractory shock
- pulse deficit
- neurologic deficit
3
Q
What are the indications for TTA in Calgary
A
Activate if any of these conditions are met:
- Suspected shock: BP LT 90 or HR GT120
- Hypothermia LT 30C
- Patients intubated for respiratory compromise or airway obstruction
- Patients GCS LT 8 with known or suspected traumatic mechanism
- Penetrating trauma head, neck, torso
- Need for PRC transfusion en route or on arrival to the ED
4
Q
What factors determine the extend of injury in GSWs
A
- kinetic engery (determined by mass and velocity)
- Bullet weight (caliber)
- Velocity (determined by weapon): high velocity (rifle), low velocity (handgun)
- Distance from target
5
Q
How do GSW cause injury
A
- Direct laceration
- Crush injury
- Cavitation
primary: bullet path
secondary (shock wave)
6
Q
In what patients can a pelvic x ray be omitted?
A
- No altered LOC
- No complaints of hip pain
- No pelvic tenderness
- No distracting injuries
- Not clinically intoxicated
- Stable patients undergoing CT (can get reformats of pelvis)
7
Q
What is the mortality reduction with TXA and when must it be given
A
Mortality reduction 1.5%
Greatest effect if given within 1 hr and some effect up to 3 hrs
8
Q
List 4 contraindication to resuscitation and transport in trauma patients:
A
- Blunt trauma with no vital signs on scene
- Penetrating trauma who are apneic or pulseless without other signs of life
- Trauma patients with >15min CPR
Transport time >15min after arrest
9
Q
List indications for ED thoracotomy in penetrating chest trauma
A
- Loss of vitals at any point with initial signs of life in the field
- Severe shock and signs of tamponade
(relative) Persistent shock (SBP
10
Q
List indications for ED thoracotomy in blunt chest trauma
A
- Blunt thoracic trauma with vitals and SBP 1500cc blood from thorocastomy immediately after placement
- (Relative) blunt arrest with previously witnessed vitals
11
Q
List 6 therapeutic maneuvers that can be performed during EDT:
A
- Heart:
o Pericardotomy to relieve tamponade
o Suture cardiac injuries
o Foley or finger in hole to control bleeding
o Open cardiac massage - Vascular:
o Cross clamp aorta à maximize blood flow to brain, reduce blood flow to hemorrhaging abdomen or extremities - Pulmonary:
o Compression or cross clamping of hilum to control major pulmonary bleed
12
Q
List the most common causes of trauma in pregnancy
A
- MVCs
- Assault
Falls
- Assault
13
Q
What % of women of child bearing age admitted to a trauma centre do not yet know they are pregnant?
A
Up to 8% in studies
14
Q
List 10 physiologic changes of pregnancy
A
Cardiovascular: - Increased HR (10bpm) - Decreased BP (DBP > SBP, return to normal by T3) - Increased CO - Decreased CVP - Increased blood volume - Reduced hematocrit - Venous congestion in pelvis - Systolic flow MM - Pericardial effusions common Gastrointestinal: - Reduced GE sphincter tone - Reduced gastric motility - Increased acid production - GERD - ALP doubles in pregnancy - Slight increase in Albumin - Increased Gall stones - Hemorrhoids Metabolism: - Insulin resistance and gestational DM - Water retention and edema - Enlargement of hormone sensitive tumors (ie pituitary)
Pulmonary: - Reduction in FRC (diaphragm elevation) - Increased O2 consumption (fetus, uterus, placenta) - Less time to desaturation - Increased Mv (volume of gas inhaled or exhaled per minute) - Hypocapnea (progesterone stimulation of respiratory centre) --? pathophys Hematological: - Physiologic anemia of pregnancy à 48-58% increase in plasma volume with only 18% increase RBC results in hematocrit of 34% at 34wks - Overall increased O2 carrying capacity - Fe deficiency - Slight immunosuppressed state - Increased coagulation factors - Physiologic leukocytosis MSK · Laxity of symphysis pubis · Incr SI joints
15
Q
List 8 anatomic changes in pregnancy
A
- Position of uterus:
- Intrapelvic à 12 wks
- Umbilicus à 20wks
- Costal margins à 23-26wks, vulnerable to direct injury - Diaphragm rises during pregnancy à More rapid tension PTx development
- Abdominal viscera displaced upwards à altered pain patterns
- Stretching peritoneum à blunted response to peritoneal irritation
- Bladder displaced into abdomen after 12 wks à more vulnerable to injury
- Bladder becomes hyperemic à more blood loss if injured
- Ureteric dilation, hydronephrosis
- Laxity of SI and symphysis ligaments
- Large breast tissue and abdomen à difficult BVM and laryngoscopy
16
Q
What is management of vena caval obstruction (supine hypotension syndrome)?
A
- Pelvic tilt to the left >15-30º (as far over a possible may be required)
- Tilting to right is less effective
- Manual displacement of uterus up and to left
17
Q
What magnitude of effect can the gravid uterus have on cardiac output and BP in the supine position?
A
- CO: 28% reduction
SBP: 30mmHg decrease
18
Q
What is the normal PCO2 and bicarb of third trimester pregnancy?
A
- Normal PCO2 = 30mmHg
Normal HCO3 = 21mE1/L leads to lowering of HCO3 slightly reduces the blood buffering capacity
19
Q
In third trimester pregnancy, what landmarks are used for chest tube insertion?
A
- 3rd or 4th interspace versus usual 5th
- Diaphragm can rise > 4cm
20
Q
What are the typical ECG changes of pregnancy?
A
- L axis deviation
- Q waves in III and aVF
21
Q
What are risk factors for fetal death?
A
- Ejections
- MBC
- Pedestrian collisions
- Maternal death
- Maternal tachycardia
- Abnormal FHR
- Lack of restraints, or improperly applied restraints
- ISS >9 (injury severity score)
o ISS: correlates with mortality, morbidity and hospitalization time after trauma. It is used to define the term major trauma. A major trauma (or polytrauma) is defined as the Injury Severity Score being greater than 15
22
Q
What is the pathophysiology of abruption in trauma? (chip in a tennis ball)
A
nelastic placenta shears way from the elastic uterus (myometrium) during deformation
- Direct blunt trauma and deceleration are equal risk factors
- Sustained contractions from intrauterine hemorrhage can also inhibit uterine blood flow, further contributing to fetal hypoxia
23
Q
What are the classical clinical findings of abruption?
A
- Vaginal bleeding
- Abdominal cramps
- Uterine tenderness
- Maternal hypovolemia (up to 2L of blood can accumulate in uterus!)
- Fetal distress
24
Q
How does a uterine rupture present?
A
- Most often from severe MVC where pelvic fractures stroke against the uterus
- Signs:
o Maternal shock
o Abdominal pain
o hemoperitoneum
o Easily palpable fetal parts
o Fetal demise - DDx: fractures spleen, liver
25
List indications to extend to fetal monitoring to > 4 hours in trauma
- >3 contractions / hr
- Persistent uterine tenderness
- Worrisome FHR strip
- Vaginal bleeding
- ROM – rupture of membranes
- Any serious maternal injury
26
What are indications for C/S after trauma?
- Fetal distress
- Uterine rupture
- Placental rupture and bleeding
- Fetal malpresentation during PTL
- Situations where uterus impairs maternal treatment
27
List indications to perform a perimortum c-section.
- Loss of maternal vital signs
28
What is the time goal to complete the perimortum c-section?
LT 5 minutes
29
List anatomic differences between adults and children that have implications in trauma assessment and management. Box 38-1.
- CNS:
o Larger head to body ratio
o Brain less myelinated
o Cranial bones thinner
- Mechanics: more susceptible to injury
o More anterior liver and spleen
o Less protective musculature and SQ fat
o Kidneys more mobile, less protected à susceptible to deceleration injury
o Chest wall more elastic à pulmonary contusions without rib #s
- CVS:
o Compensate for reduced CO by increased HR
o HR and slow CR are signs of shock
- MSK:
o Growth plates mot closed à SH #, limb shortening
o More tenuous spinal cord blood supply
o greater elasticity of vertebral column
o SCIWORA more common
30
List anatomic differences between adults and children relevant in airway management. Table 36-1.
Relatively large tongue
Large adenoids – NTI more difficult
Floppy epiglottis
Anterior and cephalad larynx
Narrow cricoid ring – uncuffed tube (now questionable)
Narrow tracheal diameter and distance between rings
Short tracheal length – R mainstem intubation
Narrow airways (R α 1/radius4) – more resistance
Laryngoscopy more likely to cause vagal stimulation
Large occiput
Higher tracheal opening – C1 infants, C3 7yo, C5 adults
Large teeth generally not a concern
Neck mobility generally not a concern
31
List indications for intubation in pediatric trauma.
1. Inability to ventilate be bag valve mask
| 2. GCS
32
What is the lower limit of normal for blood pressure?
- 70 mmHg plus 2 times the age (5th percentile)
33
What volume aliquots are crystalloid and blood replacement given?
- Crystalloid 20cc/kg 1-3 and prn
| Blood 10cc/kg prn
34
What is the volume of FFP given in massive transfusion?
15cc/kg
35
What is the volume of platelets given in massive transfusion?
· 10cc/kg with a goal of 50,000 plt/L
36
What is the volume of cryoprecipitate given in massive transfusion?
· 0.2 bag/kg to a fibrinogen goal of > 1g/L
37
What are indications for surgery in pediatric abdominal trauma? Box 38-11.
- Hemodynamic instability despite aggressive resuscitation
- Hemodynamic instability and positive FAST
- Transfusion GT 50% blood volume because of intraperitoneal bleeding
- Radiographic evidence of pneumoperitoneum, bladder rupture, Grade V renal injury
- GSW to abdomen
- Evisceration
- Signs of peritonitis
38
What chest tube drainage requires transport to the operative thoracotomy for massive hemothorax?
- Initial: >15cc/kg
- Ongoing >2-4cc/kg/hr for 3 hours
- Continued air leak
39
List 3 indications for imaging with post concussive syndrome:
1. FND
2. Progressive worsening of symptoms
3. Failure of clinical resolution >2weeks
4. Severe HA
40
Where do hematomas form in the scalp of infants?
- Caput succendaneum: Bleeding in the connective tissue layer
- Subgaleal hematomas: Within the loose connective tissuelayer, above the periosteum
Cephalahematoma: Blood underneath the periosteum (does not cross midline)
41
List 8 anatomic differences in the pediatric vs. adult cervical spine. Box 38-10
1. Falcrum changes from C2-3 in toddlers to C5-6 by age 8
2. Large heads therefore more extension / flexion injuries
3. Large occiputs LT2yo leads to flexion of cs-pine without board under scapula and pelvis
4. Smaller neck muscles
5. Ligamentous injuries more common than fractures
6. Anterior wedge shape of vertebral bodies
7. Flatter facet joints
8. Ossificaiton centres therefore can be mistaken for fractures
9. pseudosubluxtion of C2 on C3 in 40% children age 8-12
10. Predental space LT5mm in LT8yo, then LT3mm GT8yo
11. Prevertebral space size varies with respiration
12. Adult fracture patterns not seen until 15yo
13. Other more obscure ossification stuff that I can reference later
42
What are high risk and mediumrisk criteria for significant head injury in the CATCH study?
HIGH RISK
- suspected open or depressed skull fracture
- H/A worsening on Hx
- Irritability on exam
- GCS
43
What is the SN and Sp of the CATCH rule?
Sn 98%, Sp 50% if medium risk
High risk: 100% Sn and 70.2% Sp
Would CT 51.9% of all comers
44
What are the low risk criteria for clinically important TBI from the PECARN rule
AGE 3ft)
- no palpable skull #
- No LOC or LOC 5ft)
- no palpable skull #
- No LOC
- No severe H/A
- No vomiting
45
List indications for plain skull x rays
- skeletal survey in suspected child abuse
- interrogation of VP shunt
- penetrating scalp wounds
- suspected FB
46
List 8 anatomic differences in the pediatric vs adult cervical spine
1. Falcrum changes from C2-3 in toddlers to C5-6 by age 8
2. Large heads cause more extension / flexion injuries
3. Large occiputs LT2yo cause flexion of cs-pine without board under scapula and pelvis
4. Smaller neck muscles
5. Ligamentous injuries more common than fractures
6. Anterior wedge shape of vertebral bodies
7. Flatter facet joints
8. Ossificaiton centres: can be mistaken for fractures
9. pseudosubluxtion of C2 on C3 in 40% children age 8-12
10. Predental space 8yo
11. Prevertebral space size varies with respiration
12. Adult fracture patterns not seen until 15yo
47
How can true subluxation be differentiated from pseudosubluxation?
Line of Swischuck: draw a line along anterior cortical margin of C1 to C3. A normal line will be less than 2mm away from the anterior cortical line of C2
48
What are the normal prevertebral measurements in pediatrics
C2 LT 7mm
| C6 LT 14 mm
49
How is atlanto occipital instability assessed
Power's ratio
50
List 6 RF for falls in elderly
- sedative use
- cognitive impairement
- visual impairement
- Hx of stroke
- arthritis
- underlying comorbidities
51
Why are epidural hematomas rare and sub-dural hematomas common in geritraics
as brain atrophies,the dura is adherent to the skull decreasing risk of epidural . it stretches epidural vessels making them more likely to break.
52
what is the most common spinal fracture in geriatrics
odontoid type 2 fracture
common to see central cord sympotms
C1-C3
compression fractures of thoracic and lumbar spine common
53
What 3 components are essential to injury control
1. prevention
2. acute care
3. rehabilitation
54
what are the 3 components of the Hadon matrix (Injury triangle)
1. agent
2. host
3. vector/environment
55
Define mild, moderate and severe TBI
mild: GCS 14-15
moderate GCS 9-13
Severe GCS LT8
56
What are the 5 layers of the scalp
```
s: skin
C: connective tissue
A: aponeurosis (galea)
L: loose areolar tissue
P: pericranium
```
57
What are the bones of the skull
```
frontal
temporal
parietal
occipital
sphenoid
ethmoid
```
58
Describe the flow of CSF through brain
1. produced at choroid plexus
2. lateral ventricles
3. foramen of Monroe to 3rd ventricle
4. aqueduct of Sylvius to 4th ventricle
5. Foramen of Magdie and Luschka to subarachnoid space
6. drainage through venous system
59
List 3 factors that result in cerebral vasoconstriction
1. Hypoocarbia
2. HTN
3. Alkalosis
60
List 4 factors that result in cerebral vasodilation
1. Hypootension
2. acidosis
3. Hypercarbia
4. Hypoxia
61
What is the difference between direct and indirect brain injury?
Direct injury: from direct blow from another object or from compression of head
Indirect injury: from brain being in motion without direct contact b/w object and skull
62
What is the difference b/w primary and secondary TBI
Primary: mechanical damage such as contusion/bleeding/ischemia/avulsion caused by inciting event which is irreversible
Seconday: propagation of injury from lack of physiologic optimization eg. hypoxia
63
List 4 critically important secondary systemic insults.
1. Hypoxia (PO2 38.5C)
| 4. Anemia (Hct
64
List 5 causes of hypoxia in the TBI patient.
1. Transient or prolonged apnea caused by brainstem compression or injury
2. Partial airway obstruction – blood, vomitus, debris
3. Injury to chest wall
4. Pulmonary injury
5. Ineffective airway management – inability to BMV or intubate
65
What is the definition of increased ICP?
o CSF pressure greater than 15 mm Hg (or 195 mm H2O)
| o Uncontrollable ICP is >20mmHg or refractory to treatment
66
What are the types of brain swelling after trauma?
- Congestive brain swelling: increased intracranial blood volume from vasodilation
- Cerebral edema: increased brain tissue volume from increase in cerebral water content
o Vasogenic à transvascular leak due to mechanical failure of the BBB
o Cytotoxic à membrane pump failure from post traumatic tissue ischemia and hypoxia
67
What are 4 common CT findings of cerebral edema?
- Bilateral compression of ventricles
- Loss of definition of cortical sulci
- Effacement of basal cisterns
- Focal edema: adjacent to traumatic lesions à decreased density or mass effect
68
What is the cushings reflex?
```
o Associated with lifethreatening levels of raised ICP
o Triad seen in only 1/3 of cases:
o Bradycardia
o Hypertension
o Respiratory irregularity
```
69
List the 6 herniation syndromes
1. Uncal
2. Central transtentorial
3. Upwards transtentorial
4. Cerebellotonsillar herniation
5. Subfalcine herniation
6. Transcavaliar herniation
70
What is Kernohan's notch syndrome:
compression of contralateral cerebral peduncle with uncal herniation. Causes ipsilateral motor deficits. Pupuil will still blow on ipsilateral side of mass effect therefore we use the pupil for guiding bore hole
71
List 4 factors that can make the GCS less reliable in the acute stage.
1. Hypoxia, hypotension, and intoxication can all falsely lower the score
2. Intubation removes one component
3. Periorbital edema may affect eye opening
4. Extremity fractures or spinal cord injury may affect motor exam
5. Misses subtle mental status changes
6. Does not assess brainstem or papillary reflexes
72
What is decorticate posturing? What is the pathophysiology?
o Abnormal flexion of the upper extremity and extension of the lower extremity. The arm, wrist, and elbow slowly flex, and the arm is adducted.
o The leg extends and internally rotates, with plantar flexion of the foot.
o Decorticate posturing implies injury above the midbrain
73
What is decerebrate posturing? What is the pathophysiology?
o Decerebrate posturing is the result of a more caudal injury and therefore is associated with a worse prognosis.
o The arms extend abnormally and become adducted.
o The wrist and fingers are flexed, and the entire arm is internally rotated at the shoulder.
o The neck undergoes abnormal extension, and the teeth may become clenched. The leg is internally rotated and extended, and the feet and toes are plantar flexed.
74
How can brainstem function be assessed in the acute setting?
o Oculocephalic reflexes – dolls eyes
o Occulovestibular response – cold water calorics
o Cranial Nerves
o Pupillary responses (CN III)
o Gag reflex (CNs IX and X)
o Corneal reflex (CNs V and VII)
o Facial symmetry (CN VII) can be assessed if the patient grimaces
75
What are the findings of basal skull fractures (Box 41-1)?
```
Blood in ear canal
Hemotympanum
Rhinorrhea
Ottorhea
Battle’s sign (retrauricular hematoma)
Raccoon sign (periorbital ecchymosis)
Cranial Nerve deficits:
- Facial paralysis
- Decreased auditory acuity
- Dizziness
- Tinnitus
- Nystagmus
```
76
List 5 therapies that can reduce ICP
1. Hyperventilation 30-35mmH20
2. Elevate head of bed 30-45 deg
3. Mannitol IV 1g/kg
4. 3% saline 1cc/kg
5. CSF drainage
6. cranial decompression
77
What are risks of hypertonic saline therapy in head injury
1. demyelination
2. ARF
3. coagulopathies
4. Hypernatremia
5. RBC lysis
78
What are risks of mannitol therapy for head injury
1. renal failure
2. hypotension
3. decompression of hematoma from successful therapy
79
List 10 indications for seizure prophylaxis (Box 41-2)
```
Sz history
1. witnessed sz in ED
2. seizure at time of injury
3. Hx of sz d/o
Injury characteristics
4. depressed skull fracture
5. penetrating TBI
6. Severe TBU (GCS
```
80
List 4 indications for antibiotic prophylaxis in severe TBI:
1. Open skull fracture
2. Complex scalp laceration
3. Penetrating injury
(Note: does NOT include basal skull fracture)
81
What are high risk and medium risk features on the Canadian CT head rule
HIGH RISK
vomiting >2
GCS 65
signs of basal skull fracture
MEDIUM RISK
retrograde amnesia >30min
dangerous mechanism (1m or 5stairs, ped vs car, ejected)
82
What were inclusion and exclusion criteria for canadian ct head
```
INCLUSIOn
blunt trauma causing witnessed LOC
definite amnesia or witnessed orientation
initial ED GCS 13-15
injury within 24hrs
```
EXCLUSION
age
83
What is the definition of concussion
Zurich 2012: Concussion is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.
84
What are the classical finding in shaken-baby syndrome?
- Retinal hemorrhages
- Subdural hematomas
- Subarachnoid blood
No Signs of trauma
85
What is the treatment of pediatric elevated ICP
Mannitol 1g/kg slow IV over 15 min
| Hypertonic saline at 2-6cc/kg then slow 0.1-1ml/kg infusion
86
In the CATCH rule when is CT head indicated in kids with minor head injury
```
CT head needed if any of the following:
HIGH RISK
suspected open or depressed skull fracture
h/a worsensing on Hx
irritability
GCS
```
87
What 3 therapies should all patients with penetrating head injuries receive?
- Anticolvulsants (phenytoin)
- Antibiotics
Tetanus
88
List electrocardiographic abnormalities that can occur after head injury.
- Arrhythmias (i.e. SVT)
- T wave changes (diffusely large and upright or inverted)
- Pronged QT interval
- ST depression or elevation
- U waves
89
Why are complex scalp lacerations a risk for intracranial infection (even in intact skulls)?
- Emissary vessels of subgalaleal scalp drain to diploë veins of the skull which drain into the venous sinuses
90
List clinically significant skull fractures.
1. Results in intracranial air and pass through air filled spaces (sinuses)
2. Associated with an overlying scalp laceration (open skull fracture)
3. Depressed below the level of the inner table
Overlie a major dural venous sinus or the middle menigeal artery
91
What is the most common culprit bleeding structure in epidural hematomas?
- Middle meningeal artery (80%)
| - Associated with skull fractures across in the temporal region
92
At what age to sinuses become aerated
birth: ethmoid and mastoid antrum
age 3: sphenoid and rest of mastoid
age 6: frontal sinuses
age 10 maxillary sinuses
93
list the vertical and horizontal buttresses of the face
Vertical (strong): nasomaxillary pillars
zygomaticomaxillary pillars
pterygomaxillary pillars
Horizontal (weak):
superior orbital rims
orbital floor
hard palate
94
what cranial nerves mass through orbital foramina
CN I, III, V (opthalmic branch) ,VI
95
what glands make up the salivary system and what drains them
parotid gland drained by stensen's, submandibular gland drained by Wharton's , sublingual glands drained by ductules adjacent to wharton's
96
Describe LeFort injuries of the face
Type I: fracture through maxilla above roots of teeth
Type II: maxilla and nasal bridge lacrimal bones and orbital floor
Type III: Type II but with posterior extension laterally through orbital flood and lateral orbital wall exiting through zygomatic arch
97
List 4 physical findings to suggest orbital blow out fracture
Entrapment of inferior rectus
Infra orbital anesthesia (midface/upper lip)
Endopthalmus
Step off deformity
98
What is the DDx of diplopia in facial trauma
Inferior rectus entrapment
CN III injury
Direct muscle injury
Enrapment of periorbital fat
99
What is superior orbital fissure syndrome
Injury caused by fracture around superior orbital fissure
| Paralysis of EOM (CNIII), ptosis (CN III) periorbital anesthesia (V2)
100
What is orbital apex syndrome
superior orbital fissure syndrome plus blindness (CN II)
101
List 5 indications for prophylactic antiobiotics for facial wounds
```
devascularised
contaminated
through and through buccal
ear cartilage
bite wounds
```
102
list indications for prophylactic antibiotics for facial fractures.
```
- Open fractures
# that violate a sinus
```
103
List local complication of oral electrical burns.
- Full thickness commissural burn of lips
o Cosmetic complication à Microstomia
o Bleeding from labial artery (as maturing eschar separates at day 5-21)
104
What is treatment of auricular hematomas?
Drainage or I & D
| o If 48hrs but
105
List 9 symptoms and signs of vision threatening orbital compartment syndrome.
```
Symptoms:
- Pain
- Decreased vision
- Painful EOM
Signs:
- Proptosis
- Restricted EOM
- RAPD
- Increased IOP
- Diffuse subconjunctival hemorrhage
- Marked periorbital edema
```
106
List the fractures make up the Tripod (Trimalleolar) fracture of the face
- Lateral orbit
- Zygoma
- Maxilla
On exam they may have enopthalmos or malocclusion of upper teeth +/- maxillary teeth anesthesia (dentoalveolar nerve from anterior wall fracture)
They require operative repair as they procduce a “sink” deficit if left alone
107
Who can be discharged with a spinal fracture?
- Minor wedge fracture (
108
Where anatomically does the spinal cord terminate caudally?
L2
109
What are the soft signs of penetrating neck trauma
```
Soft (8): Think complications that deal with blood, air, nerves.
1. Hemoptysis, hematemesis
2. Oropharyngeal blood
3. Non-expanding hematoma
4. Dyspnea
5. Dysphonia, dysphagia
6. SQ or mediastinal air
7. Chest tube leak
focal neurologic deficits
```
110
When is cervical spine immobilization required for penetrating neck injury?
1. Coexistent blunt trauma
2. Evidence of cord injury
(Note: Incidence C Spine # with penetrating injuries: stab wound 0.12%, 1.3%)
111
What are contraindications to Cricothyroidotomy in neck trauma?
- Age
112
What is the only hard sign of airway trauma?
- Air leaking through a neck wound
113
List other signs of laryngotracheal injury.
- Subcutaneous emphysema
- Dyspnea
- Hemoptysis
- Dysphonia
- Stridor
- Cough
- Crepitice
114
List “soft” signs of esophageal injury.
- Hematemesis
- Blood in saliva or NGT
- Odynophagia
- Subcutaneous emphysema
- Other : Dyspnea, hoarseness, stridor, cough, pain and tenderness, resistance to passive neck movement
115
What is the management of esophageal injuries?
- Broad spectrum antibiotics (anaerobic coverage) +/- NG tube to decrease spillage
- Surgical exploration
Non-operative management of most isolated pharyngeal injuries
116
What are clinical features of laryngotracheal trauma?
- Bubbling from the wound (only hard sign)
- Massive subcutaneous air
- Bony crepitus over the larynx
- Other (dysphonia, aphonia, dyspnea, stridor, hemoptysis, subcutaneous emphysema, laryngeal crepitus, neck tenderness or pain over the larynx, visible neck wound, loss of anatomic landmarks due to hematoma)
117
List the 4 “hard” signs of vascular injury.
- Pulsatile bleeding
- Expanding hematoma
- Bruit
- Focal neurologic deficits
118
List the 3 “soft” signs of vascular injury.
List the 3 “soft” signs of vascular injury.
- Venous oozing
- Nonpulsitile, nonexpanding hemaotomas
Minor hemoptysis
119
What vascular injuries can result from blunt vascular trauma?
- Intimal tears
- Thrombosis (delayed Sx, 24hrs)
- Dissection (note – intracranial more likely to dissect because the artery wall lacks an elastic layer, making it more prone to dissect).
- Embolization
Pseudoaneurysm
120
What is Calgary’s approach for investigating potential BCVI in blunt trauma?
CTA is indicated in 24 hrs if that patient has any of the following features on history or exam:
- Severe injury mechanism: severe cervical hyperextension/rotation or hyperflexion associated with any of the following:
o Displaced midface (LaForte II or III)
o Complex mandibular fracture
o Closed head injury with DAI
- Near hanging resulting in anoxic brain injury
- Physical signs:
o Seatbelt neck abrasion or other neck injury with swelling
- Basil skull fracture in proximity to ICA or VA:
o Vertebral artery – foramina transversum
o ICA – carotid canal
- C Spine injury: body fracture in previously normal spine (not degenerative or pathological)
121
What is the treatment for penetrating and blunt vascular injuries?
- Penetrating: Primary surgical repair vs. ligation
| - Blunt: anticoagulation or antiplatelet therapy, surgical repair / ligation / thrombectomy, or stenting
122
Differentiate judicaial and nonjudicial hanging.
- Judicial (complete hanging)
o Ligature around the victims neck and a drop resulting in the victim being freely suspended
o Classically fall > height of the body
o Forceful distraction of the head and body
o High cervical fracture, complete cord transaction and death
- Non judicial (incomplete hanging)
o Partial suspension of the body with some part still in contact with ground
o More likely in a confined space
o Fractures are rare
o i.e. attempted suicide
123
Contrast the mechanism of death that results from judicial vs nonjudicial hanging:
- Judicial:
o Forceful distraction of the head from neck à high C spine #’s (ie hangman), complete cord transection, and death
- Nonjudicial:
o Initially venous congestion causes stasis of blood flow and loss of consciousness
o Once the person is limp, the ligature tightens further causing arterial occlusion and brain injury or death
o Vagal reflexes and carotid sinus stimulation may contribute to fatal arrhythmias
o Compression of the airway does not seem to play as important a role
o Airway compression does not play as significant a role as vascular occlusion
124
List the pulmonary complications of near hanging and strangulation.
```
- Pulmonary edema
o Neurogenic (poor prognosis)
o Post obstructive
- Bronchopneumonia
- ARDS
```
125
List the non-pulmonary complications from hanging and near strangulation:
- Vascular damage
- Laryngeal injuries
Thyroid cartilage fractures
126
What are Tardieu’s spots?
- Petechial hemorrhages in conjunctive, mucus membranes, and skin cephalad to ligature marks (Highly correlated with asphyxial deaths)
127
List the common causes of immediate and early death from chest injury
Immediate: aortic rupture, myocardial rupture
```
Early (30 min- 3hrs)
Tension PTX
Tamponade
Airway obstruction
Exsanguination
```
128
List 5 indications for CT chest/aortography after 1st rib fracture
- Direct evidence of vascular injury
- Direct evidence of neurologic injury
- Associated major head, thoracic, abdominal, long bone injury
- Additional rib fractures
- Widened mediastinum on plain films
- Large hemothorax
- Large apical hematoma
- Intercostal artery injury
- Brachial plexus injury
- Significant displacement of the fracture
129
List complications of rib fracture (early and late)
```
Early:
hemothorax
PTX
TPTX
pulmonary contusions
atelectaiss
pneumonia
```
LATE
posttraumatic neuroma
costochondral separation
130
Define flail chest.
3 or more adjacent ribs are fractures at 2 points, allowing a freely moving segment of the chest wall to move in paradoxical motion
131
Describe traumatic asphyxia.
- Syndrome caused by severe compression of the thorax by a heavy object
- 1/3 lose consciousness at injury
- Marked increase intrathoracic and superior vena caval pressure
- Blood flows retrograde from the right heart to the great veins of the head and neck (which do not have valves) and allow engorgement of the capillaries of the head and neck with blood
- Deep violet skin color, bilateral subconjunctival hemorrhages, petechiae, facial edema
132
What causes disturbances of vision in traumatic asphyxia?
- Retinal hemorrhages (permanent)
| - Retinal edema (transient)
133
What causes subcutaneous emphysema (where does the air come from)?
- 1. Extrapleural air
o Extrapleural tears in tracheobronchial tree allow air into mediastinum and soft tissue of neck -- pneumomediastinum
- 2. Intrapleural air
o Intrapleural lesions allow air to into pleural space via viceral pleura and through parietal pleural into thoracic wall – pneumothorax
- 3. Esophageal tear (Boerhaave’s sundrome)
o Pneumomediastinum and subcu air over supraclavicular area and anterior neck
- 4. Extrathoracic air
o Immediately adjacent a penetrating wound of the thorax
134
What is suggested about the cause of the subcutaneous emphysema by its location?
- Chest wall: Pneumothorax
- Supraclavicular area and anterior neck: Mediastinum
Massive swelling of the face and neck from subcutaneous air: Ruptured bronchus
135
How are simple pneumothoraces graded from CXR?
- Small: LT15%
- Moderate: 15%-60%
Large: GT60%
136
How are pneumothoraces sized by the AACP (American Academy of Chest Physicians *refers to spontaneous pneumothoraces and is only consensus).
- Small
137
List the cardinal signs of tension pneumothorax.
- tachycardia
- JVD
- Absent breath sounds
138
List 10 indications for tube thoracostomy for pneumothorax (Box 45-1).
1. Traumatic cause (except asymptomatic
139
List complications of tube thoracostomy.
- Hemothorax
- Pulmonary edema
- Bronchopleural fistula
- Pleural leaks
- Infection
- Empyema
- Subcutaneous emphysema
- Contralateral pneumothorax
140
List indications for Urgent OR thoractomy for hemothorax (Box 45-2).
1. Initial drainage >20ml/kg (roughly 1500mL)
2. Persistent bleeding at a rate of >7ml/kg/hr (roughlu 200mL/hr over 3 hours)
3. Increasing hemothorax on CXR
4. Hypotension despite adequate blood replacement, other sites bleeding ruled out
5. Decompensation after initial response to resuscitation
141
How is diaphragmatic rupture diagnosed?
- Chest tube affluent with DPL (historical)
- CT not SN enough
- Best is at laparotomy or exploratory laparoscopy
142
Outline your approach to the workup of a cardiac contusion (Based in EAST guidelines):
```
IF you suspect blunt cardiac injury based on mechanism or symptoms and the pt is:
- Hemodynamically UNSTABLE
o Needs Echo (TEE)
- Hemodynamically STABLE
o Get screening ECG
o If Normal - you're done
o If AbN - 24h of cardiac monitoring *most don't actually do this UNLESS there is a pattern of acute ischemia.
- No role for cardiac biomarkers.
```
143
What is Beck’s Triad (pericardial tamponade)
- Hypotension
- Distended neck veins
Distant muffled heart sounds
144
What are potential clues to air embolism?
- Hemoptysis
- Cardiac arrest after intubation and PPV (almost always the case)
Often from bronchvenous fistula à an intervention during thoracotomy is to soak the chest with saline and identify fistula as the frothy bubbling wound
145
How much air is needed for lethal air embolism?
- Right Sided venous air embolism/pulmonary air embolism: 5-8mL/kg
- Left Sided arterial air embolism/systemic air embolism: 0.5mL
146
What is the most common location for blunt aortic injury?
- Descending aorta at the isthmus, just distal to the subclavian artery 90%
o Also occurs at the ascending aorta proximal to the brachialcephalic branch.
- 25% associated cardiac injuries (tamponade, valve, CA injuries, contusion)
- Due to the whiplash effect: DA is tethered, and during deceleration the mobile arch swings forward putting stress at the isthmus
147
List clinical feature suggestive of blunt aortic injury?
- Interscapular or Retrosternal chest pain
- Generalized hypertension à reflex HTN from afferent sympathetic NS fibers in Ao isthmus in response to stretch
- Pseudocoarctation: HTN UE and hypoTN LE
- Harsh systolic murmur
- Swelling/hematoma at the base of the neck
148
How sensitive if wide mediastinum on CXR for aortic injury?
- 50-92%
| Specificity 10%
149
Provide a differential for wide mediastinum on the trauma CXR?
```
Aortic dissection
AP film
thymus (child)
malignancy/mass
Fracture: sternal, clavicular with bleeding, thoracic spine
pulmonary contusion
poor inspiration
magnification artifact
esophageal rupture
```
150
What are commonly sited measurements to define the wide mediastinum?
- Supine AP: 8cm
- Erect PA: 6cm
- AT aortic knob: >7.5
- Mediastinal:thoracic ratio >0.25
151
List additional features on CXR that are evidence of aortic injury.
```
Loss of AP window
Left hemothorax
wide mediastinum
Obscured aortic knob
Displaced NG tube to right
wide paratracheal stripe
depression of mainstem bronchus GT 40 degrees from horizontal
Left apical cap
tracheal deviation to R
```
152
List 7 causes of esophageal perforation.
```
Caustic burns
FB
Boerhave's
Blunt injury
penetrating injury
post op anastamosis breakdn
Iatrogenic
```
153
What Esophageal anatomic feature allows direct access of stomach contents to the meduiatinum in the case of esophageal perforation?
- Absence of a serosal layer
154
What is the classic chest radiograph of esophageal rupture?
- Mediatinal air with or without subcutaneous air
- Left sided-pleural effusion
- Pneumothorax
- Widened mediastinum
- Lateral C/S: air or fluid in retropharynx
155
How is suspected esophageal peforation investigated?
- CT may provide a clue to the diagnosis, but don’t tell you the etiology
- Esophagography (gastrografin) swlaoow PLUS
- Endoscopy
156
How do patients with esophageal rupture present?
- Pleuritiuc CP along esophagus exacerbated by swallowing or neck flexion
- Pain in epigastrum, substernal, back
- WOrsend over time, migrate from upper abdo to chest
157
What is the ED management of suspected esophageal perforation?
- Broadspecturm antibiotics (including coverage for orral flora eg clinda)
- Volume resuscitation
- Airway managment
- Surgical consult
158
Which organs are most likely to be injured in adult blunt abdominal trauma?
- Spleen
- Liver
Small intestine
159
Which organs are most likely to be injured in pediatric blunt abdominal trauma?
- Spleen
- Liver
kidney
160
Define the thoracoabdominal box:
- Circumferential line at Xyphysternum
| - Inferior costal margins inferiorly
161
List injuries are associated with lap belts.
- Mesenteric laceration
- Intestinal injury
- Ruptured diaphragm
- Acute abdominal aortic dissection
- Injuries to the lumbar spine (ie - Chance fracture)
162
What is the pedestrian struck triad of injuries?
1. Head injuries
2. Torso injuries
Lower limb injuries
163
What is the definition of intra-abdominal compartment syndrome?
- ACS is a clinical syndrome characterized by progressive intra-abdominal organ dysfunction from elevated intra-abdominal pressure (IAP)
- Normal IAP = 5-7mmHg; Intra-abdominal htn >12mmHg
ACS = IAP >20mmHg with new organ dysfunction
164
List steps in DPL.
- NG/OG Tube
- Foley catheter
- Identify location
- Local anesthetic
- Prepare abdomen in a sterile fashion
- Insert catheter in percutaneous (Seldinger), semi-open or open fashion
- Attempt aspiration of free blood (if positive stop, >10cc frank blood)
- Instill lavage (1L warmed NS; 10cc/kg in a child), followed by gentle agitation, and drainage by gravity
- Assess cell counts of fluid
165
List 7 clinical indications for laparotomy following penetrating trauma
- Hemodynamic instability
- Peritoneal signs
- Evisceration
- Diaphragmatic injury
- Gastrointestinal hemorrhage
- Implement in situ
Intraperitoneal air
166
List methods of determining peritoneal violation in abdominal GSWs.
- Missile path
- Plain films
- Local wound exploration
- US
- Laparoscopy
CT
167
List 5 clinical indications for laparotomy in blunt abdominal trauma.
1. Unstable VS with strongly suspected abdominal injury
2. Unequivocal peritoneal irritation
3. Pneumoperitoneum
4. Evidence of diaphragmatic injury
5. Significant GIB
168
What is the significance of blood at the urethral meatus?
- Diagnostic of urethral injury
- Mandates early retrograde urethrogram
- Precludes Foley catheter placement until urethrogram has demonstrated an intact urethra
169
What are the usual mechanisms for anterior urethral injuries (bulbous and pendulous) vs. posterior urethral injuries (membranous and prostatic)?
```
- Anterior urethral injury
o Straddle injury
o GSW
o Falls
o Self instrumentation
- Posterior urethral injury
o Pelvic fracture involving pubic rami
o Note: the prostatic urethra is tethered to the posterior symphysis à a fracture can result in laceration of avulsion
```
170
List 4 indications for a retrograde urethrogram:
1. Blood at meatus
2. High riding, boggy prostate on rectal exam
3. Inability to pass a catheter in context of trauma
4. Penile, scrotal perineal hematoma
171
Classify bladder ruptures.
- Extraperitoneal
- Intraperitoneal
Combination
172
What are 2 relative indications to investigate for possible bladder rupture?
- Gross hematuria
| - Microscopic hematuria with pelvic fracture
173
When should pediatric patients be investigated for renal injuries?
- Blunt renal trauma and gross hematuria
- Blunt renal trauma and microhematuria >50RBC/hpf
Significant deceleration injuries
174
Name the three masses of penile erectile tissue.
wo corpus cavernocum (dorsal)
- Corpus spongiosum (ventral)
- Blood supply: 2 dorsal penile arteries, deep/superficial penile veins
Nerve supply: Dorsal penile nerve
175
What is a penile fracture?
- Traumtic rupture of the corpus cavernosum with tear of tunica albuginea
176
What is the clinical picture of penile fracture?
- Pain and audible snapping sound during vigorous sexual intercourse
- Followed by detumescence and penile hematoma
- 10-40% have concurrent urethral injury (gross hematuria, inability to void, blood at meatus)
177
Differentiate traumatic lymphangitis from Peyronie disease?
Traumatic Lymphagitis
- Translucent firm nodular cordlike configuration beginning at coronal sulcus in subcutaneous tissue
- Involves one side of the penis or encircles it
- Usually not tender and is freely mobile
- Due to vigorous or prolonged sexual intercourse or masturbation
- Treatment is abstinence for 2-3 weeks and NSAIDs
Peyronie’s disease
- Plaquelike fibrosis in the dorsal tunica albuginea between two corpus cavernosa
- Decreases penile distensibility with dorsal curvature
- Leads to painful erections and difficult or unsuccessful veginal intercourse
- Due to repeated microtrauma
- Management is daily vit E (400IU) and urology follow up
178
List Injuries associated with blunt scrotal trauma:
- Testicular rupture (seen in 40% of blunt scrotal trauma patients that come to ED)
- Scrotal hematoma
- Traumatic torsion
- Testicular avulsion
- Testicular displacement
- Epididymal injury
- (Note: these need to be Dx with ultrasound)
179
List testicular injuries that require operative management.
```
- Blunt:
o Rupture
o Large hydrocele
o Traumatic torsion
o Dislocation
- Penetrating wounds or dog bites into intra-scrotal contents
```
180
What is the management of testicular contusions?
- Bed rest
- Ice packs
- NSAIDS
Urologic follow up
181
What is generally the limit of warm ischemia time before irreversible damage begins to occur?
- 6 hours
- >6 hours 10% irreversible damage
- >12 hrs 90% of pts will have irreversible damage)
If limb is cooled it undergoes cold ischemia which can extend tolerance of ischemia up to 24hrs
182
Differentiate occlusive form nonocclusive vascular injuries.
```
OCCLUSIVE
All effective perfusion is lost distally
o Transection
o Thrombosis, embolus
Reversible spasm
```
```
NON OCCLUSIVE
some arterial flow continues past the injury
o Intimal flap
o Dissection
o AVF
o Pseudoaneurysm
```
183
Differentiate acute from delayed thrombosis.
- Acute thrombosis
184
List treatments for reversible spasm in trauma.
Conservative
- Topical warm saline -
- Topical nitroglycerin
```
Aggressive
Infusion of vasodilators
o Nitroglycerin
o Nitroprusside
o PGEs
o CCBs
o Alpha-blockers
o Warm saline
```
185
Differentiate a true aneurysm and a pseudoaneurysm.
True aneurysm:
- >50% increase in size
- All three layers of the artery (intima, media, adventitia)
- Rarely traumatic
Pseudoaneurysm:
- Hemorrhage from a vessel contained with fascia which over time forms a fibrous capsule resembling an aneurism in consistency
186
List the complications of a pseudoaneurysm.
- Compression of adjacent structures
o Neuropathy, Venous obstruction, Erosion of bone
Embolization of mural clot: distal arterial occlusion
187
List 6 “Hard findings” of vascular injury:
1. Pulsatile bleeding
2. Expanding or pulsatile Hematoma
3. Distal limb ischemia: the 5 Ps (Pain with passive stretch, Pulselessness, Pallor, Parasthesias, Paralysis)
4. Cyanosis and temp differences
5. Audible bruit
6. Distention of distal veins (in AVF)
* Incidence of arterial injury with any hard finding is consistently >90%
188
List 5 high-risk injuries that should make you suspicious for vascular injury, even in the absence of hard or soft signs:
1. Crush injuries
| 2. Proximal penetrating injuries (
189
How is API usually used in the context of a potential arterial injury (Rosens)?
- API ≥ 1: Normal
- 0.90 - 0.99: Merits observation and repeat physical exam, +/- CTA
API
